The Process of Cultural Competence

in the Delivery of Healthcare Services

"Cultural competence is the process of becoming;

not a state of being."

Josepha Campinha-Bacote

"The Process of Cultural Competence in the
Delivery of Healthcare Services," is a culturally
consciously model of care
thatdefines cultural competence as "the
process in which the healthcare professional continually strives to achieve the
ability and availability to effectively work within the cultural context of a
client" (family, individual or community).
It is a process of becoming culturally competent, not being
culturally competent. This model of cultural competence views cultural awareness, cultural knowledge, cultural skill, cultural
encounters and cultural desire as the five constructs of cultural competence. Cultural
awarenessis defined as the process of conducting a self-examination of
one’s own biases towards other cultures and the in-depth exploration of
one’s cultural and professional background.
Cultural awareness also involves being aware of the existence of documented
racism and other "isms" in healthcare delivery.
Cultural knowledge is defined as the process in which the
healthcare professional seeks and obtains a sound educational base about
culturally diverse groups. In
acquiring this knowledge, healthcare professionals must focus on the integration
of three specific issues: health-related beliefs practices and cultural values;
disease incidence and prevalence (Lavizzo-Mourey,
1996). Cultural skill is the ability to conduct a cultural assessment to
collect relevant cultural data regarding the client’s presenting problem as
well as accurately conducting a culturally-based physical assessment.Cultural encountersis the process which encourages the
healthcare professional to directly engage in face-to-face cultural interactions
and other types of encounters with clients from culturally diverse backgrounds in order to modify existing
beliefs about a cultural group and to prevent possible stereotyping.Cultural desire is the motivation of the healthcare professional
to “want to” engage in the process of becoming culturally aware, culturally
knowledgeable, culturally skillful and seeking cultural encounters; not the
“have to.” Cultural
encounters is the pivotal construct of cultural competence that provides the
energy source and foundation for one’s journey towards cultural competence.

As we begin,
continue, or enhance our journey towards cultural competence, we must continuously
address the following question, "Have I ASKED myself the right
questions?" The below mnemonic "ASKED" represents the self-examination questions
regarding one's awareness, skill, knowledge, encounters and desire.Although the
below mnemonic
can assist healthcare professionals in informally assessing their level of
cultural competence, healthcare professionals may want to
formally assess their level of cultural competence. For this purpose Dr.
Campinha-Bacote developed the instruments, Inventory For Assessing The Process
of Cultural Competence Among Healthcare Professionals - Revised (IAPCC-R)
and Inventory For Assessing The Process of Cultural Competence Among
Healthcare Professionals - Student Version (IAPCC-SV), which are based on her model of cultural competence and have established
reliability and validity. Please refer to the website links on the
IAPCC-R (link) and
IAPCC-SV(link)for more information and psychometric properties regarding these instruments .

Awareness: Am
I aware of my biases and prejudices towards other cultural groups, as well
as racism and other "isms" in healthcare?

Skill: Do I have the skill of conducting a
cultural assessment in a sensitive manner?

Knowledge: Am
I knowledgeable about the worldviews of different cultural and ethnic
groups, as well as knowledge in the field of biocultural ecology?

Encounters:Do I seek out face-to-face and other types of
interactions with individuals who are different from myself?

Desire: Do
I really "want to" become culturally competent?

Background
Development of The Model (1991-2010)

The following comments reflect the development of
Campinha-Bacote's model of cultural
competence in healthcare delivery. For more detailed information about
the model refer to the publication,
The Process of Cultural Competence in the Delivery of
Healthcare Services: The Journey Continues, 5th edition (2007) published by Transcultural
C.A.R.E. Associates. If you are interested in obtaining a copy of
this publication, please refer to the following link:Resources. Please note that the
four graphic/pictorial figures displayed on
the bottom of this web
page (as well as the above mnemonic ASKED model) are copyrighted and cannot be reprinted without formal
written permission from
Transcultural C.A.R.E. Associates. Thank you for your understanding of the
intellectual property and legal copyright status of these models.

The
development of my current model of cultural competence has been an ongoing
process of 19 years. This process began in 1991 when I conceptualized and named
the model, "Culturally Competent Model Of Care." In this first
version, I
identified four constructs of cultural competence: cultural awareness,
cultural knowledge, cultural skill, and cultural encounters (figure 1, below).
However, in
1998 I revised my initial conceptualization of
the model for the constructs were very limited in scope and needed to be expanded to include new knowledge in the field of
transcultural health care, and the pictorial representation of this model
appeared linear. This first version of the model did not clearly depict cultural
competence as a "process" and the pictorial representation did not express the
interdependent relationship between the constructs. I also felt that cultural
competence was more than just awareness, knowledge, skill and encounters.
Therefore, in the second revision I added
a
fifth construct called cultural desire, modified the pictorial
representation of the model as a Venn diagram to reflect the interdependent relationship between the five constructs, and expanded the
definitions of the constructs of
cultural awareness, cultural knowledge and cultural skill
(figure 2, below). I renamed the model, "The Process of Cultural
Competence in the Delivery of Healthcare Services," to reinforce that it was
a process. In 2002, the
key role that cultural desire played in the process of becoming culturally
competence became evident, yielding further revision of the model's pictorial
representation. I
enhanced the model to symbolically represent a volcano. In this pictorial
revision, cultural desire was identified as the construct that ignited the
process of becoming culturally competent. (figure 3, below). Finally, in
2010, I began collecting evidenced-based research studies using my model
and tool (IAPCC-R),
and discovered that the pivotal and key construct in the process of becoming
culturally competent was cultural encounters. With this added
research-base knowledge I amended the pictorial representation to focus and
center around the construct of cultural encounter (figure 4 below).
The current model begins and ends with the
seeking and experiencing of many cultural encounters and it is only through
continuous cultural encounters that one acquires cultural awareness, cultural
knowledge, cultural skill and cultural desire. From this perspective, cultural
competence can be viewed as an ongoing journey of unremitting cultural
encounters.